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020-1165-00-000 (2)
i - Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 487920 0 GENERAL INFORMATION (ATTACH TO PERMIT) � State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Hii I er's City Village X Township Parcel Tax No: h &Joan Hudson, Town of 020 -116 -00 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 07.29. .994 996 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Ila 00- 100-0 Dosing /] Yiif�h /'� I . Alt. BM ' /CFO. v Aeration f�"ilVty �1 (7�V Bldg. Sewer r Holding St/Ht Inlet TANK SETBACK INFORMATION SUH Outlet U TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet 4. (j Z 6 73- - n 1--- Septic i Dt Bottom 0-AX 3 ( Header an. /. Y Aeration Y � Dist. Pipe O �� Holding Bot. System E a, b g 8 a 2- Final Grade PUMP /SIPHON INFORMATION H1% il0 e4vt �' Z • y Manufacturer 15emand St Cover GPM " Model Number�� �_ D TD H Lift Friction Lo Sys a TDH Ft Forcemain LenZJ6 Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS f /� SETBACK SYSTEM TO P/ BLDG WELL LAKE /STREAM LEACHING anufact�p€�� INFORMATION CHAMBER OR 1/171 Type ystem: 3� / �' UNIT Model Number. qLSTRIBUTION SYSTEM I1 .I, C Header/ �}nnlifold IDistribution x Hole Size x Hole Spacing Vent to A r Ir9ke 9 J'SL— 1 -e g ' y p 9� �— �f Q Len th Dia Len th Dia i S acin O SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only `l 1(4 Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched ! Bed/Trench Center' Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) rte/ Insp� n #1:10/ 0 0 Inspection #2: Location: 307 Ed ewood Drive Hudson, WI 54016 (SW 1/4 NW 1/4 1 T29N R W) Edgew to t 64,65 &6 7 Parcel No: 07.29.20.994 996 9 < _/ / % 1.) Alt BM Description - l4� 2.) Bldg sewer length = Q�ts-h� baA syy k r ajtQGvy vk;(v - amount of cover Plan revision Required? Yes I'No i', • Use other side for additional information. — -- -- —L O S - - - - -- - - -- - Date Insepctor's Signature Cert. o. SBD -6710 (R.3/97) and County �r p �, NVISCO, 1Q.� visi Ca 201 W Ave., P. 162 J 1 `i F—t/ �- adison, — 7162 , � r 't.�� (608) 266 -3151 Permi Number (to be filled in by Co.) Department of C mmerce' a 8 92-0 �/ J Sa its P_ �'iGp 'cation state Plan 1.1). Number N /T� In accord with mm S!3 information you provide may be fors mercy Law, s15.04(l Xm) Project Address (if different than mailing addre I. Application Information — Please Print All Information dZO. S Property Owrrer•'s Name - oo • odcoo e,4 G 0�4 �!>G t ' U 13 P Co , �o S (0 B lock # Property Owner's Mailing Address 3 �� 1 00 0 P PA - sW ,� N *-) -7 Cn tate Zip Code Phone Number Se ction ctior f. rev Gc) /. 71 S • 3�� • J� G L �l ' �l cc ircl T rW H. Type of Building (check all that apply) N; R 3 )L or 2 Family Dwelling - Number of Bedrooms V Subdivision Name CSILN_t er ❑ Publi- Wommercial - Describe Use 60 IJ O O0 •� �� s ❑State Owned - Describe Use ❑City ❑Vi}lageQy,gf IIL Type of Permit: (Check only one box on fine A. Complete line B if applicable) jj V � OAD A. ❑ New System )(Replacement System 11 Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. El Permit Renewal ❑ Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS stem: Check all that a Non - Pressurized In- Ground ❑ Mound > 24 in_ of suitable soil ❑ Mound <24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Pat Filter ❑ Aerobic Treatment Unit Dywrrulatin F, ❑ r Recirculating Synthetic Media Filter XLeachiftg Chamber ❑ Blip Line ❑ Gravel -less Pipe ❑ Other (explain V. Dispersalfrreatment Area Information: t �,.w. Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sfj Di al Area Pr Syst evation 5 5 o o l is. VI. Tank Info Capacity in Total Number Manufacturer refab Site Steel Fiber • Plan is Gallons Gallons of Units Li a — /Co ncrete Constructed Glass Now Existing /ks Septic or Holding Tank Tanks Ta nks I O W `� 0 Aerobic Trealmoat Unit "Af Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's N e {Print) luqjtierls Signature MP S Number Business Phone Number �.7,1�b�2i azC�31s s'• - 2 - 23•3gV Plumber's Address (Street, City, State, Zip Code) 24 1 Z- D 17Y . <Smiwi - P/0 4 S VIII. Conn /De artment Use Ont Approved ❑ DisapDroved Sanitary Permit Fee Jocludes Groundwater Date Issued Issuin Agent Signer (No Stamps) Surcharge Fee)_ t ❑ ear Reason ial IX. Conditio Ap ro 1 3� 0 � _ Q S ►r��c� �n� r�{� SYSTEM OWNER; 1 Septic tank, effluent filter and �[ 1 /_ _ (; A L _ _ n dispersal cell must all be serviced / maintained �2 u as per management plan provided by plumber._ U , 1 2. All setback requirements must be maintained ►^"QaM$ a- / as per applicable code /ordinances. `6eQ Attach complete plans (to the Coos o for the sy an County o nly) ys Paper not Ies n 81/2 x 11 inches in size S) F- +-�s $_ a,-Q -e A- -�� SBD -6398 (R. 01/03) nQ.,��u�►�si4 l T JO .r /D o ,�' ►� Gv /�� r' X11 � t y !3 1011 1, Lol P1 � vt x► i i { s;�Div y p p, L L s E� � oL� y sT ,N rAc r V/ A J3v /l r Ilk 10 $ r rM M aF °1 � X 1,57 3 i KiS POWT SYSTEM SHALL INCORPORATE PER COMM. 83.44(2)c A PROPER ZABEL ULBRICHT & ASSOCIATES CO. 2812 10th Ave. - Spring Valley, Wl 54767 Reg. Designers of Engineering Systems 715 -772 -3442 Private Sewage Consultants PROJECT INDEX PLAN ID # DATE OWNER N PHONE ADDRESS 3 07 6 W 0 00 '0 0 LEGAL DESCRIPTION Ste, ,vcv, ''7, T��, ,P� w Pr r, • I� / s" ao • M-06 TOWN OF s 79it� D(F rp COUNTY CSTM LOCAL AUTHORITY/ SUPERVISION ST . C lUt X " y. ZdA�r�'�Cf PROJECT DESCRIPTION: 5 z •�t,e., . �x�' s rl�v �� cby /. WA-) 2 • P-t, Soli, T e - s t : G'e7:7 /ti ,4 2 2. Ulbricht & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 Pg.l INFILTRATOR SIZING WORKSHEET eq Pg.2 SYSTEM PLOT PLAN P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS_ Prr - 4 F, - CO) 44 AFS CL a z 0. C 0 a , b 1 0 n m � � m fl a � o � pra t t o 0 6 10 %104 I N r3�cf x► '� i i 13 ©o-A4 o f s:p%tiy foo, 0 1 ► . a ---- o L� s ysrE•y 1 T& G.4f �7T /.v 7A c T 11.4 13 / � v� � OF �.5 _ y f q s ys T, 3 i KiS POWT SYSTEM SHALL INCORPORATE PER COMM. 85.44(2)0 A PROPER ZABEL FILTER monm * i iA.% - - • . C�ltv��T"�7? t �,�.s/����o.t.� • cep �� � F i ff s y�WA4 6 5S 5E a .SfitJ r 7eA 7 - 0je ,5 • Qo G_ 1 /S w� 1q .sr? FT, ®.�o c,�P�c�r y I s�i - -.e�,� c�,o,S s� � s�• - f� , AbOMAIh vr07 c i ° //,a • ISpF�Tig,�, I POINTS OWNER'S MANUAL & MANAGEMENT PLAN Page . of FILE lNFORMATIONi SYSTEM SPECIRCAT1oNS Owner RA tL (r V����� Septic Tank Capacity � �""+� ga l ❑ NA Permit # l Septic Tank Manufacturer j�y-�` ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer L ❑ NA Number of Bedrooms �? El NA Effluent Filter Model 13 NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) .360 g al/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) �,j� gal /day Pump. Manufacturer ❑ NA Soil Application Rate g al/day/ft /ft2 Pump Model ❑ NA Standard ! uent Quality Monthly average eatment Unit D NA Fats, Oil & Grease (FOG) <30 mg /L ❑ and /Gravel Filter 13 Peat Filter Biochemical Oxygen Demand (BOD <220 mg /L ❑ NA Mechanical Aeration ❑ wetland Tot S <150 m ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD <30 mg /L In- Ground (gravity) ❑ in- Ground (pressurized) Total Suspended Solids (TSS) <30 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) _ <10 cfu /1 ❑ Drip -line ❑ Othe Maximum Effluent Particle Size Y in dia. NA Other. ❑ NA ❑ NA . Other: Other: L I . p T t Ti"w 1�-- - ❑ NA 'Values typical for domestic wastewater and septic tank effl(ent. Other: EI NA MAINTENANCE SCHEDULE Service Ever Service Frequency Inspect condition of tank(s) At least once every: ❑ y th(s) (Ma)dmum 3 y ew) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (y) of tank volume ❑ NA inspect dispersal cells) At least once every: ❑ month(s) (Ma)dmuetl 3 ears) ❑ NA year(s) Y Clean effluent filter At least once every: month(s) ❑ NA year(s) Inspect pump, pump controls & alarm 0 At least once every: O month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: El month(s) ❑ NA Other: ❑ year(s) A. At (east once every: ❑ month(s) ❑ year(s) - [3 NA Other: ❑ NA, MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shalt be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 1 13, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any-service event. Ulbricht & Associates Private Sewage Consultants 2812 1 Oth Ave. Spring Valley, Ail 54767 > Z. START UP AND OPERATION pass of For new construction, Prior to use of the POWTS check treatment tanks) for the t m impede the tr eatment hat m Presence of Painting - products or othet chemical: of the tank(s) removed by a septage servicing ent process and/ damage the dispersal cell(s). If high concentrations are detected have the content: operator prior to use. Svstem start up shall not occur when soil conditions are -frozen at the infiltrative surface. During Power outages pump tanks may fill above normal highwater levels. When po discharged to the dispersal cells) in one large dose, overloading the cells) and may result. i the lb ackup backup surrfa d charg of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating "the pump controls tc restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal coils. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All Piping to tanks and pits shall be disconnected and the abandoned Pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of a Septage Servicing Operator. • After pumping, all tanks and Pits shall be excavated and removed or their covers removed and the void; space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant reps ement system: 6 suitable replacement area has-been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells Failure to result in the need for a new soil and site evaluation to establish a suitable replacement pr a R lacement�ent area w comply with the rules in effect at that time. P systems must El A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. D The site has not been evaluated to identify a suitable replacement area. . t)pon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. Q Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUF OXYGEN_ DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS ia POWTS INSTALLER Private Sew Corl SUltarlts POWTS MAINTAINER Name 2512 Wtnl V . Name Phone , 4 (1 one SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name _ �' .5 ,(f! ` TA 7 0/ 4_) Name 57 J( C � ZO ill t ti7 (hone Phone / 3 �6 This document was drafted in compliance with chapter Comm 83 . 22 (2)(b)(1)(d)&(f) and 83.54(l),12) & (3), Wisconsin Administrative Code. Ulbricht & Associates OWNER's MAINTAINCE--oF'.SEPTIC SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance'of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of system. The owner is required by code to submit all necessary- maintenance/inspection reports to the controllin au g, thorities. SPECIFIC CONTACT AGENTS Governmental authority/ inspectors: . * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: S * Licensed service 1 inspection - agent other than installer: 13C.cw Nole6__ 41 * Electrician, for pump, electric controls, wiring units: #'mac IMPORTANT OWNER MAINTENANCE RE UIREMENTS 1. Winter traffic (sledding, shoveling, etc.) across the area shall not be permitted, or frost can /will penetrate into the cell, freezing up the system. Oiscontinuos use in the . Winter_(a vaeact -ion trip, resulting in no water.use) can -also lead to freeze ups. 2 . Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This sysem was designed for a maximum wastewater flog of { ' ` gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage. disposal unit, or any other unnatural sources o€ waste _ .. Any introduction of such waste'matersals will overload and destroy this system. 4. If a power outage - occurs, or a pump fails, it .may ; result in a temporary overload of effluent being pumped into the cell. which may adversely impact the cell (leakh'ge). It is recommended that a licensed pumper empty the dosing tank, allowing the pu to return to dosing the correct amounts. Consult your installer immediately for advice. 5 . Neglect of the vegetative cover erosive {the cells insulation & preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system.. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! the s Effluent in ystem beneath IS NOT sufficient alone to Effluent y$ `= povwr. maintain a 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated into the system: on the mound basal area (effluent 1pvoi e Wmandnoepwanwtof EVAL REPORT Page of 3 Division of Safety and Bins ''�r atxordttnce wan ss. wts. Adm. code Alfachomvv)k a We pmt an tta _ t;c � size. lPlen must co�xtty $? • �'D �?� p to ve and ocationamiddistarme n road. Patel Li) Please print all irdtarreat OM = by Owe t+ewo�tkfomason yoe predg"mo rt - umsdtors8o0Mdaryw■vM" (PAVWuL*W. s. 15.04 0) t�31 1 67 ( �v7�'c/� �— Govt. Lot t 5W 114 IM S T2. N t � ! E c Owner's Maft Ad*m Lot # Nodr # aft Name or csw 9d G W40d b lP7 £s*?kS MM code Nurt�ber p try ❑ ~ Town Nearest Roil 7u psodl W1 - 1 sal d o , H v�.aaPj ; n& woed dam. Ljw IX Resdet vd i Ntsntw of bedrooms . 3_ Code derived dull now tie GM p Pumarca Nwardw -ow"IM Patent tnatetl a v Tv,*& r+ 1* / LG — Flood Plain devagcro if app&=We Q tt. c3etteral cottrrtertts atd Area Spot Tested sWtft * tot a conventional inground system P P Q 10 Pit Gtotm staiaoedev. 3.56 iz NO to kdft bdar lim sea AppNoWn Rob Horimrt Depth Oorttittartt Colin Radorr Desaipt M Tetdure Sttttcture CwskWm Sotmdwy Roafs it tip Qa. SL coat. Color ter. Sz. Sh :2 f b1K 1YlfR 2 //--" ID lfR4 IC 3 f bK Mfi 'V 4 3 4! . SYR4 - S w► K M+r A W -- . 4 / . o i SS D bb•�z%ti2, - 4 2 �- t�rot,�dst,%wdw. 9i. 92 R t�ptn fo BrttNrg tutor 19s' so 0404c"M Pea Hot= Oap#t Dominant calm Rsdotr DM&%O tt Teomxe SWAM" CottsiMrce Boundary kocfs GPM in. Wool! D<t. SE Cot& Cdor M S>r Sh t 0-2 IVYR - — A 3-f &K rn ..g 2 2 JOYR /b - .5 le, l 2M bx 3 WYR 41, - Se.l 2a) bin m fr a W I ik( .mot- . to 3 IoYR s � - — • 5 !.o 4 .,.d�. g3.o • EtAttettt#9 = am > M zM ttta and TSS xv < IM mgll. EflUtent 22 = BOD _ .V nW& aad M S W M0_ ca ^S A, ise P" Saxe J1d&vn tae Evaluation Cottdi cW O Telephone er Mwil lo A��. Rte u. W t ra -13-b� 71S 77Z For issuance of permits and designing Contact: Ulbrich & Associates Registered private wastewater consultant and plUmbefs 2812 10th Ave. OVA Spring Valley, WI 54767 -ran -�A AA AA Property owner Parcel ID # Page 2 of 3 Boring F3-1 fid 0 soltv p cd /-57 rt. depth to WnOV ftclor > 9l H,. Sol AppficWom Rabe How Depth Dm* wt Calot Reft Desa"m Te*" Structi" CaWdence &u-W y Roots G PM i — Munsell Qu. Sz Cent Color Gr. Sz Str. 'EW 'EW a_�o �nY 3� 2f b fi 34 -(0 . g 2 -28 W it -4 / C / of bx f-i a S , b 3 2$ T S'1R 411 - S l 2 rn bx m-fr w y 53-9 WYK 54 s o S5 m I BMV D Pit Gmuwwrtmceelew. tt. DepM to �s factor in. sw Awkcaffm fiats Horst DomkwIt cola Red= Texture Shcture Consf BowvWy Roots GPM im L%Xvsa Qu. Si Cart. Color Gr. Sz. StL 'EM 'E*Z F # BofuV Pit GroundsurfaGeetev ft Depth do Wnft factor in. Sol Rate Hodzm Depth Domim"Cokx Redax Dam" m. Texture Sure ConsWenOe 8ourtdaty RO t Mtn Qu. Sr- Cant Cfldor Gr. ST- Sh. axkv F # 0 ❑ Pd Ground surface etev. ft. Depth to factor in Soil App&xWm Rare Horizon Depdte DM*mt cckx %xIax Desaip M. TW*AM Sdi� ©ortsisi,artoe Bourtdary Roofs G in Murtse)E Qu. ST- Cont. Color Gr. Sz. Sh. '! t " Fdw CL �f3•Sb A ,gy &97 wCtp DRIVE ' e o P OF yJELi -= E�'�IAtFN? 100.00 ate. 0 9' �1 3 4 b ...._.... 4 � f IS 01-c> 5 .r-,• / � �� $ 9557 � l EST rnna-rEu / C N O T SA W F3oT`T�M a F l f OA) AS BU ILT) S i Crnit� , 92 'C"`7 I3oT?bM O � Oc. D OrRACW &IBDY'E Q W S ys - rem = lq.42. o r, © Sys-Tr' 23' = tl S iv SO uTrt PfZO Pe�' -"rat' 4./Nr 3 • BOtzrNt�S a � CoNTouRS ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ? OwnerBuyer �� L /� f O f t/ G/e" B &K 6j , c� �� ' 2. Ci � Mailing Address 3o ��w 0 0y �• Property Address (Verification required from Planning & Zoning Department for new construction.) City /State ,�'j�s'�'� yt/ Parcel Identification Number d a'o //(0 'S LEGAL DESCRIPTION Property Location 5 '/4 , N 1) 1 /4 , Sec. , T ` N R W, Town of C �y.Gs- Subdivision g pq LO DO G S 7` �'�s , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3 7 Volume , Page # s�o s• Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. - Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNATURE OF AP ICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Ulbrich t Aswiates el Privat wage Consultants 2812 1 Oth Ave. 0 nrinn \lallav \A /1 rd7F7 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This Is to ce rtify that I have inspected the septic tank presently serving the / cigGA 0- &CC`�,y aell,GL ' residence locat.:d at: 5 0 1/4, /VA) 1/4 Sec. 7 T N R W � Town of !� Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time service �� S Did flow back occur from absorption system? Yes X No (if no, skip Approximate volume or length of time: gallons next line) _______.minutes Capacity: Construction: P e refab Conc rete St eel Other Manufacurer ( If known) : Gc9%�,1&7e Age of Tank (if known): (Signature) (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (3.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative ratio e Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for Inspection p P ope ning P over R s outlet baffle . Name �jl� G Signature Mp /MPRS 5/88 Ulbri ht c & As sociates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 DOCUMENT NO. STATE BAR OF WISCONSIN FORM I —19911 FA C RU CRV IM Von pWAI 01140 DATA WARRANTY DEED 3'9'M4 i�� -VOL 'I9 EGVERS OFFICE anson, a I T. C"X T eed, made between ................................................ ... �� F. H ............ ............................... ! .:�c's�. �Ixotd this 2 6th .' 51�Z ..1 ...................... ... D. l9 d-Jy of Nov. A. $4 ........... .... ......................:.......- . ........... .............._..............., Grantor, lii M' and ......_ Ralph -D, • (ckenfi.eLge.s?. husbmnd . and wife.,.. aa.. J.Q; Wt.. tenaFit, ................ . ..... i! .................. ................., Grantee, ............... ................... ............ 1 Witnesseth, That the said Grantor, for a valuable consideration...... One. n . other.. valuable .CoMid�eratiaa ............. I IIaTURN To conveys to Grantee the following described real estate in ._ _._. S. -•••• j; Bank Of New Rickmoond County, State of Wisconsin: i c h mand, WI 54017 el No: Lots 64, 65, and 66, Edgewood Estates, located in the Sh of the NR of Section 7- 29 -19, Town of Hudson, St. Croix County, Wisconsin, Subject to recorded easements, reservations, and rights of way. 1 . This ...... i3 . homestead property. ......... . (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; F Hansotlti .................. And....... ..................... ............................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except no exceptions and will warrant and defend the same. .......... day of ................ 1S.... Dated this ..........20th N... •- ( SEAL) T�ZJ•.. (SEAL) F. Hanson i ............................ ......... ............ ............................... (SEAL) . ......... (SEAL) i i ............. . ............ .................. - AUT$ENTICATION ACKNOWLEDGMENT Lax F. Hanson STATE OF WISCONSIN Signature(s) ` ........... ............................................. ... . ................... ss. ... .................................. ............................... ......County. authen is Oth gy NCR eTTbe_r 19. Personally came before me this . day of � - 19........ the above rained ................ . .-------- •_.... .. . . . . .. ..................... ......................... . . . . .. ............ . EricJ Lundell ... ................... ........ ................. . . . . .. ........... -_ - - -- .............. ................. TITLE: MEMBER STATE BAR OF WISCONSIN .....................•. ...............•......__....... Ifnot . ............................................................. _._...__....._.... - authorized by $ 706.06, Wis. Stats.) to me known to be the person ............ who executed .the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED By Eric J. Lundell Box 157 Z I V V. O S`i L Z N C4 .Of'4S -00'96 , 00' 6 I n ' `+ O N • '°I K M V. w M M al k° d i Z ° �' • v � N � � ,..� � r � ♦ 9 C' T I .ti* ta e"'' .. V = ;00`9.6 cc 3 .�d,£bsa • �LC'9fL M «L9.9Lo 8 .C9't�6 .00''94 .Oa�6� o� w I � I �^ o .Lg' , p y� 1 � w w :03 �T w .0o• _ I 9s — I III t Z Z4 a V. � w Y :.. a O �°, fEL arrow a d 0 sf•LCL M »t v.s L s `�� 4 LL�at+ota •0'0'06 .00'f �ry i 'a , YJ'NY�'1r3 1 / L L $ �� •�f'Zi •t t'�k .: 0i .fry I W z .o ra * � 'f w o © * ,;� • • as c w m ►= Z w uj N 00) 032053 C 1 s f i 12 - LA cc, 3 , 0 r � � k •a �\ dr - - 01 9 C7 m 0! 3Mn �y .► •+ m O V CD 13 rr eo a (A -1 j Z O Cat 2 Z f(D C d O y O = O ao V CD 7 fD tD CO f/1 a O x y C n N N Cl I O N a co '* CD m 3 w a 0 w w v rn CD 0 o w gD m m cn < D .. cc cn Z W p m <a N a (n CD cn D a O lco I m M V co m c o _ m N 3 0 j CO a 0 .. fC O L � W OO�f A co r < Z N 0 N 2 a N 3' °1 3 CL M. Ul < Z 0000 0002 o. I� Mv0CD I 0 c go 0) ujC �°°� of a °'o�l 0) N �• 3 d CD cr 3 m° °' rm CL Z O 0 0 y F o D o c 0. o in - b o -b N m CD CD W CD y I C Co y O O C C CD C 3 CD a 7 I N . 7. 7 7 C N fD C CD w d a a a v 3 7 3 7 Z m cC (n -y En Ln w a n o. a W W M G co Ni N <D 0 CD Z M 3 O. A C '•' C "•' Z N C C O y Z �< < W A W N d c d C � C 7 3 N N N CD a M. y D A CL M I I — C �J w v fn A rn o 0 o CD m N R 0 0 0 o 0 o 0 ° o� 4_ 7 t Parcel #: 020- 0 01/07/2005 04:57 PM PAGE 1 OF 1 Alt. Parcel 7.29.19.994 -996 020 - TOWN OF HUDSON Current ST. CROIX COUNTY, WISCONSIN Creation Date oricaI Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * GUCKENBERGER, RALPH & JOAN RALPH & JOAN GUCKENBERGER 307 EDGEWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 307 EDGEWOOD DR SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 1.085 Plat: 1929 - EDGEWOOD ESTATES SEC 7 T29N R1 9W EDGEWOOD ESTATES LOT 64, Block/Condo Bldg: LOT 64 65, & 66 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 07- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 49040 232,400 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.085 33,400 146,400 179,800 NO Totals for 2004: General Property 1.085 33,400 146,400 179,800 Woodland 0.000 0 0 Totals for 2003: General Property 1.085 33,400 146,400 179,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 204 Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 a Form - ST C- 104 �v AS BUILT SANITARY SYSTEM REPORT OWNER ' TOWNSHIP Lv?S�_ SEC. T ,)�N- a ADDRESS WISCONSIN S ST. CROIX COUNTY, WI IN SUBDIVISION LOT ,S' LOT SIZE PLAN VIEW Distances and dimensions to m et requirements of H 63 SHOW EVERY HING WITHIN 100 FEET OF SYSTEM s of k y , i s f , '4 INDICATE NORTH ARROW BENCHMARK: Describe the ve tical reference point used Elevation of vertical refer ce point: /�./} Proposed slope at site: ? SEPTIC TANK: Manufacturer:; ��,! ;:;,,` Cauacity: //1/7n r PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: i Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: r Length: ) Number of Lines _ Area Built Fill depth to top of pipe: Numbe of feet from nearest property line: Front, /Vl\ Side, O Rear, O Ft <_ r Number of feet from well: Number of feet from building (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: I DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING; LABOR & MUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISIOP P.O. BOX 79 BUREAU OF PLUMBING MA($VSQk I 1 53707 ff* CONVENTIONAL ❑ALTERNATIVE Stale Plan l.D. Number : (l ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound f assigned) r AME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE Larry Hanson R. R. 2, New Richmond, WI .. ' l—gly BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.: i SW NW, Section 7, T29N —R20W, Town of Hudson, Lots 64,65,66 Name of Plumb er: MP /MPRSW No.. County: Sanitary Permit Number: Cal Powers 1563 St. Croix 54991 SEPTIC TANK /HOLDI TANK: MANUFACTURER. L ID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCK IN O R / n Q PR V ED: PROVI 4 t.49— '1 '4 . a EXYES ONO ❑ S ONO BEDDING: V NT IA.: VENT MATL HIGH WATER NUMBER OF ROAD: PROPEF�TY � WBU�I VENT TO FRESF ALARM FEET FROM 5 LINF/ f I � Al I cT. DYES O ❑YE O NEAREST ✓1 (/ DOSING CH MBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMB OF PROPERTY WELL. BUILDING: JVENTTOFRESI (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FOR the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDT LEN TH NO. OF DISTR. PIPE SPACING. COVE J INIIDE DIA.. $PITS: LIQUID ijTR >i TRENCHES MA PIT DEPTH: � 4) 2. GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PI MATERIAL' N0. TR NUMBER �F PROPERTY WELL. BUILDING: VENT TO FRESF BELOW PIPES ABOVE CO ER. ELEV. INLET. ELEV. END PIPE FEET FRAM LINE: AIR IN v 1 •7 Q •(off 'Z ? G� N;EAREST 5 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES ONO DYES NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED: SEEDED: MULCHED. CENTER. EDGES: 1:1 YES ONO OYES ONO ❑YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: TRENCHES. MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR, DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. y � dlk! 1 ELEV.: ELEV.: DIA.: ELEV.- PIPES DIA.; al�l� HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. E1 YES ❑NO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: N MI�E #08; PROPERTY WELL: BUILDING: FIST' FR )W Z 3 ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ` L Sketch System on Retain in county file for audit. Reverse Side. TURE: - TITLE: DILHR SBD 6710 (R. 01/82) [=mw�� wisconsin APPLICATION FOR SANITARY PERMIT � ' DILHR COUNTY �� OE PRRTTrI en T OV (PCB 67) UNIFORM SANITARY PERMIT # mmd� In0USTRY,LR801 6MUTgn gELRT10n5 ���/�/ Y — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRIt4T PROPERTY OWNER A ING ADD ESS .2 .;� �' J J I J PROPERTY LOCATION CIT-y 1/4 1/4, S , N, 'G� (or) W TOw= o IfYKr LOT NU BER BLOC NUMBER SUBDIVISION NAME NEARE T ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: j ❑ Public (Specify): THIS PERMIT IS FOR A: A New System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity s^ y Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation a private sewage system shown on the attached plans. N7 of Plumber (P t►: Si at MP /MPRSW No.: Phone Numb r: 9 - �/Z (i - Plumber' Address: Name of Designer: X Z�Z - COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved n �jl `� �, / �DL ❑ Owner Given Initial a 7 / ( p 4 / Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber s INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private Y sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. I s APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property >- , Location of Property Ejj �4 '4, Section �_ , T N - R W Township Mailing Address I i Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created /,' /,/ / Are all corners and lot lines identifiable? 'X Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (ale) eeAtii y that a t e-totementA on ,tW �otm ate tttue to the best o6 my (out) knowledge; that I (we) am (arse) the owners (h) o� the pnopvtty de�5eru.bed in thi,6 kn4oamation 4or7xn, by viAtue o6 a wa,rAan,ty deed Ae oAded in the 066ice o6 the County RegiAteA o4 DeeA ass Document No. ? 'rc• and .that I (we) prceisentty own ,the O&opo.6ed site 6orc ,the 1sewage po�sae /System (arc I (we) have obtained an e_aaement, to tun with the above deseni-bed prcopeAty, 4ot the con.6-ttuetion oL,6aid 6 y.6 tem, and the same hays been duty tecoAded in the 066ice o� the Coq y Re .us-teAc� Beds, as Doeumen� No. ) . �j� PAGE f RE GI" 7*1 ' :;;� a GOS2 ST. �i , -, 1X CQ ., 5th A F F I D A V I T day of Sept._q - () j 84 of 3:4 P. o Eii, STATE OF WISCONSIN) James O' Connell ) SS Q�ceetn of D �� c °°`�� . ST. CROIX COUNTY ) ` �h� - D . Deputy I, James E. Rusch, Registered Wisconsin Land Surveyor, hereby depose and say: That I have surveyed and platted Edgewood Estates, located in the SE 1/4 of the NE 1/4 of Section 12, T29N, R20W , and in the SW 1/4 of the NW 1/4 of Section 7, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; That there is a proposed on -site liquid waste disposal system intended for, and a percolation test completed on Lot of said plat; That said system is intended to serve a home intended to be built on Lot of said plat; And that I make this affidavit to inform all future purchasers of said Lots and of the possible existence of said system. /. and sworn to bef ore me this day of • �a -M ...1 usc�i - : �:,Not%ry�Public,?5tate of Wisconsin lviy QQmrn ?ji expires June 14, 1987 This instrument drafted by: James E. Rusch a a- r ST C- 105 r y SEPTIC TANK MAINTENANCE AGREEMENT C St. Croix County C r OWNER /BUYER n ROUTE /BOX NUMBER Fire Number CITY /STATE E J d ZIP (`=� PROPERTY LOCATION: Section T N, R W, w F�/ Town of /'r .St. Croix County, Subdivision Lot number Improper use'and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the Septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -eite wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning ce wit in 30 days of the three year expiration'date. / SIGN DATE 7 �7 St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. i O ric r N � ? N O m -e -a < o o CD a3 �`a :r 0) Q p C O =r 3�m�0 c C N CD C r. N N g ... 0 CD C� (D o (D w CL U) 7 n --% m N r! = Nom, 0) n .+ �; `� ? -+ O o m° C o w o 0 � ? =r to O p, t_ Q► N .�. C C A O.Z? C gym W N w M =cam o� 1 m w A N C -% < Q m Q D C o cl c= 'aom°'of O n -% ... m on -% �s C Co -v 30 '• N 0 N � N p � * � Z o N C m '% ? O ? O -� .• o a .. � ? c w � o'Nm W O 3 to N ?wo � c w � m m O 0 O N o cm M 0.0 ft aic rn CL cl CL CL O m Q A S m N �n C - -% 0 0 oC K�.� m M. O �m� N. A -, � o N a .� o c C a '� m n Boa. �cmQ'. o.S 3 o o - ..3 • - a o Z. :z }Y b EPARfMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY; DIVISION HUM RELATIONS PERCOLATION TESTS (115 MADISON W 7 (H63.090) & Chapter 145.045) LOCATION: t SECTION: WNSHIP /M +T-Y: L IVO.:BLK. :SUBDIVISION NAME: 1`I' '/4 / (or) W 5 Ly OUNTY: 4 OW ER BU ER' NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MA E NO. BEDRMS.: COMMERCI L DE CRIPTION: r�New ❑Replace IPROFI E DESCRIPTIONS: ER O ATI N TESTS: ,Residence J i {O ,� 0 z i RATING: S= Site suitable for system U= Site unsuitable for system ' CONVENTIONAL: MOUND: IN- GROUND PRESSURE: [YSTEM-IN-Fl LL HOLDIN TANK: RECOMM NDED SYSTEM:(optional) [4 sa ou as u os u If Percolation Tests are NOT require DESIGN RATE: If an portion of the tested area is in the under s.H63.09(5)(b), indicate: ) , Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHIN. ELEVATION OBSERVED EST. H17HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) Z i B- °� } J 1 L ? - B- PERCOLATION TESTS 'l TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL -MIN, PE RIP0 1 PERIO 2 PERIOD PER INCH P- 7 -." P_ 2 S P : ? Il t S P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION " I ,2'_� e l _ - /Q i IN I� 7 , € i t - § .y. y e INSTRUCTIONS FOR COMPLETING FORM 115 - SRI - 6395 `s To be a complete and accurate soil test, your I eK>ort must incimle: e description; 1. Co�taplc.t legal desc�ripti , 2. The use section must clearly indicate whether this is a residence or commercial Project; 3, MAXIMUM number of bedrooms or commercial use planned; 4, Is this a never or replacement system; S. Cornplete the suitabili rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE usc; the abbi eviations shown here for writing profile descriptions and completing the plot plan; 1. MAKE A LEGIBLE diagram aecurately Ic rating ycxrr test locations. Drawing to scale is preferred, A tserwaite shcet may b used of desired; S. fv ,Ial e srmm lour be;ichrnark and vertical elevation seferenee point are. clearly shown, and are permanent; F. Complete all appropriate iate boxes as 'to dates, names, addresses, flood plain data, percolation test. exemp- t(C r , if appropriate; 10. If the ;nformatiorl )such as floor] plain, elevation) does riot apply, place N.A. in the appropriate box; 11. Sign the form and place your cure #ant address and your certification numher: 1 2. AA ke legible copes , md distribute as required. ALL SOIL. TESTS MUST BE FILED WITH THE LOCAL AUTHOR ITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Text €Tres Other Symbols s t Sf)ni' £over t ") BFI Bedrock Cob - Cooblrr (3 - 10 ") SS — Sandstone (Ir — Gravel 'tundGr T ") LS — Limestone s _ Sand HGW -- High Groundwater perc -- percola.tiorr Rate rne''s __ rtu&ur Sarxl W - k"'I'3 rs - Fine S<a,ad Bldg — buildin !_cmany Sand `y _ Greater Th >1 y `,rawc[v L aa,n r _ Less Thar Bn Brourm I it Site Lo« Er B1 -- Black S G __ G rO` y r 1,w Loam y yeilmv s(` - -_ Sandy Clay 1. oa;n R — Red sicl — S Ity Clay Loam mot Mottles -`lay cl S'lly Clay fif few, fine, fain*. pt -- Pont I m — many, Ine'dium ,rar;k d _ distinc<. p -- promir ent HAIL — High veate level, ;v-a + ,., Six f ;e.��,a, soil t.ex�eares surface ,rater for hfj id wastH disposal BM — Bench Mark VRP — Vertical Referenco Point TO THE OWNER PAGE OF sy� CroSS 1 3 'iu 04 a 13t Sy C -) Fresh Air Inlets And Observation Pipe ^- Approved Vent Cap Minimum 12" ADOVe Fin al Grade 20- 42" Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe lsareh Nay Or SynlMlk Coverina - Mln. 2" ApOrepale Over Pipe Distribution Pipe 0 0 0 0 — Tee Be Aa PIP: Perforated Pipe Below gal — 1 — Cowpling T::minallnp .A: Bottom Of Syetem P t Ink 9 SOIL FILL DISTRIBUTIOAI PIPE APPROVED S'JOTIETIC COVER u "MAT OR 9" OF STRAW 2 OF A6G RE GATE --�� OR JAARSN HAY t LEV. OF� F E�T�. o (o OF 12 - 2'/2 AGGREGATE DISTRIgJTIOtJ PIPE TO BE AT LEAST ILJCHES BELOW ORIGIIJAL GRADE AIJD AT LEASTZO IAICHES BUT KIO MORE THA1J H2 INCHES BELOW FINAL GRADE MAXIMUM WrIi OF EXC FK otl OK I GWqL bi(Ao€ WILL BE �-2 INCHES MINIMUM DE " OF EXCAVATIOW fKo^ 01k 1`41I+qL 6Rao€ WILL BE - INCHE S SIGUED: - 0!!!!Z LICEUSE IJUMBER: DATE: _ � •`�` MR, EAMON !LAN". no..� _■ ■ ■ ■ l ■■e ■ e e mom ■■e ee ■ ■■■■■ 1 1 No OMEN ■ ■ ■■ ME ■ ■ ■1 1 ■ ■■■■N ■ ■ 1 11 ■ ■■ ME NO ■■ ■r ■■■ 11 ■ ■■■ aWAN ■ ■■■■ 1 0 MMM dl ■ ■■ Ir��� N ■■ ■ I ■ ■ ■ ■■ ■ 1 Iy e ■■ " l�JIIS ■■NEE ■ee 1■e ■ ■ ■ 1 Ile■ ■ Il11 a■�.___ ■■ ■ 1 11■■ �IIIII �l■1�■■■■■■ �■ ■ ■■ ■■1 11 ■■ ■ ■loll 1 ■■ ■li■ ■ ■■ ■ � ■ ■ ■ ■ ■■■ ■1 1 ■�e 1 I ■ 0 ON ■■■ 1 11■ _ ■ rsr■ ■ ■fie 1 !I ■ ■: iio■■ ■ ■ ■ ■■ ■ e e■ e■ 1 ■■ e ■ �I ■e e■ ■ Ell ■se ■ ■ El ■■ ■ ■■■s■■ ■ ■■ ■ ■ ■ ■.■ ■.■■■ ■■ ■ ■ ■ ■ ■ ■ ■ ■ ■■�